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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700251
Report Date: 04/27/2022
Date Signed: 04/27/2022 06:04:16 PM


Document Has Been Signed on 04/27/2022 06:04 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:BROOKFIELD HOME CAREFACILITY NUMBER:
312700251
ADMINISTRATOR:MCGILL, RAMONAFACILITY TYPE:
740
ADDRESS:5342 BROOKFIELD CIRCLETELEPHONE:
(916) 415-1012
CITY:ROCKLINSTATE: CAZIP CODE:
95677
CAPACITY:6CENSUS: 5DATE:
04/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Administrator Ramona McGillTIME COMPLETED:
06:15 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Talwinder Bains and Kerry Hiratsuka arrived at the facility unannounced on 04/27/2022 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPAs met with Administrator , Ramona McGill , and explained the purpose of the visit. Prior to initiating the annual inspection, LPAs completed required COVID-19 testing protocols, the daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPAs wore the following Personal Protective Equipment (PPE) during today's visit: surgical masks.

LPAs and Administrator toured facility together to ensure the health and safety of residents in care. Areas toured include but are not limited to: kitchen, common areas, five bedrooms, two bathrooms, medication closet , garage, laundry room and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed.

LPAs and Administrator completed the infection control domain together and there were a couple of issues that were found:

This facility is not following the infection control plan that was submitted in 2021. The facility does not have a complete visitor log that shall include screening for infection symptoms, staff wearing masks, daily screening of residents and staff for infection.

Also found during today's visit: garage is used as a sleeping area and a closet inside the facility is also used as a sleeping area and they do not have a fire clearance. This is a zero tolerance and results in $500.00 immediately civil penalties assessed. Licensee did remove the bed from the garage and bed in the closet during visit and stated she shall not use the areas for sleeping. The garage may be used as a break area, but cannot be used to as a permanent occupied space or as living space.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: BROOKFIELD HOME CARE
FACILITY NUMBER: 312700251
VISIT DATE: 04/27/2022
NARRATIVE
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Deficiencies cited under Title 22, Div 6. See LIC 809D. A $500.00 immediate civil penalty was assessed during today's visit. Failure to correct the citations shall result in civil penalties that shall accrue.

Exit interview conducted and copy of report left at the facility. Appeal rights given.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 04/27/2022 06:04 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926


FACILITY NAME: BROOKFIELD HOME CARE
FACILITY NUMBER: 312700251

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State FIre Marshall. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshall.

This requirement is not met as evidenced by: A bed found in the garage was used for sleeping and a bed found in a closet was also used for sleeping by staff. These areas are not fire cleared.
Deficient Practice Statement
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Based on observation Licensee failed to ensure staff sleep in areas cleared by fire inspectors which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/28/2022
Plan of Correction
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Areas not cleared for sleeping in shall not be used for sleeping.

***CLEARED DURING VISIT. ALL BEDS WERE REMOVED AND THE LICENSEE STATED SHE WILL NOT USE THEM UNLESS SHE HAS A PERMIT AND FIRE CLEARANCE.***
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 04/27/2022 06:04 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926


FACILITY NAME: BROOKFIELD HOME CARE
FACILITY NUMBER: 312700251

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(c)
Infection Control Requirements. An Infection Control Plan shall be developed by the licensee and shall be included in teh Plan of Operation as required by Section 87208

This requirement is not met as evidenced by:

Deficient Practice Statement
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Based on observation, record review, and interview, the licensee did not comply with the section cited above in There are no daily screening logs for staff and residents for signs of infection, and staff needed reminding to wear masks and the visitor log was not complete by lacking symptom screening. which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/27/2022
Plan of Correction
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Licensee shall submit in writing how she shall ensure there are logs for daily symptom screeng for staff and residents, ensuring staff wear masks at all times, and the visitor log is complete.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4